Discovering Tuberculosis: A Global History, 1900 to the Present by Christian W. McMillen (review)

Tuberculosis continues to be a disease of historical and contemporary importance—and as Christian McMillen exemplifies in this book, it continues to fascinate those who study it. Existing TB historiography is extensive, ranging from traditional progressive narratives through to texts exploring the social and cultural dimensions of disease in different times and places. However, there is a lack of material covering the period from the 1940s onward, and McMillen carves out a niche for his work by using as his time frame a “long” twentieth century that runs from the 1880s to 2014. The result of extensive archival research given a contemporary focus, much of the material here will be new to readers. However, it should appeal to both the TB specialist and the generalist alike, because there is a comprehensive bibliography and because McMillen has a straightforward and engaging writing style (although there is the occasional repetition). This book isn’t only about TB though; it will be useful for those interested in the history of changing attitudes toward disease and race, the development of global health policy, and the history of the World Health Organization (WHO). It is also the story of where we were in terms of controlling TB in 1900 to where we are now—which in McMillen’s view is primarily a journey of failure.

Structurally, the book is in three parts, bounded by a short introduction and conclusion. Part 1 charts the use of race as a tool for explaining the observed variance in TB etiology within different populations. This section is perhaps the weakest, in that it lacks contextualization. McMillen argues that the “virgin soil” theory espoused by Lyle Cummins in the early part of the twentieth century (that certain populations were uniquely susceptible to disease until evolutionary-acquired immunity occurred, meaning external methods of disease control were unnecessary) was based on no statistical evidence. For TB this concept proved to be remarkably persistent, but there is little acknowledgment that Cummins’s conclusions were based on clinical observation, the dominant explanatory paradigm of the time. Notwithstanding, McMillen’s skill here is to show how the gradual realization that TB was a disease brokered by social conditions (overcrowding and poverty) rather than race resulted in the mobilization of global efforts to tackle it.

Part 2 focuses on TB control between 1935 and 1975. The world was watching to see if preventative and curative interventions in North America, India, and East Africa were successful, and if so whether they could be replicated elsewhere. McMillen’s conclusion is that although technically biomedical solutions were available, practically, the need for biosocial remedies too meant that global programs could be difficult to implement under differing local scenarios. This is particularly well evidenced in chapter 6, which charts the short-lived but effective anti-BCG vaccination movement in South India during the 1950s. Always contentious, McMillen suggests that BCG (the most widely used vaccine in the world) epitomizes all that is problematic in TB control—scientific uncertainty, “innovation and … inertia … hope followed by despair” (p. 76). As far as treatment is concerned, a case study of chemotherapy in Kenya and material from India provide evidence that many of the problems associated with treatment failure today—inadequate prescribing or access to drugs, and the importance of structural, social, and cultural support for patients—were problems in the 1950s too.

Part 3, titled “Failure,” explores the WHO’s choice of strategies to control TB from the 1970s within the context of the cost-effectiveness of prevention versus cure. McMillen argues that the WHO’s continued pursuance of global solutions to local problems without sufficient program evaluation and its sluggish response to the challenges posed by HIV-associated TB and multi-drug-resistant forms of the disease have led to an era of lost opportunities for disease control.

Whether or not one agrees with all the conclusions reached, this is a...